HomeMy WebLinkAboutItem No. 10 Agreement Early Learners City of Lake Elsinore 130 South Main Street
Lake Elsinore,CA 92530
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LS www.lake-elsinore.org
Di.,.. pInt.-I Text File
File Number: ID# 17-689
Agenda Date: 6/26/2018 Version: 1 Status: Consent Agenda
In Control: City Council/Successor Agency/Public Financing Authority File Type: Report
Agenda Number: 10)
City of Lake Elsinore Page 1 Printed on 612112018
CITY OF
4
LADE ! LSI O E
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DREAM EXTREME
REPORT TO CITY COUNCIL
To: Honorable Mayor and Members of the City Council
From: Grant Yates, City Manager
Prepared by: Beau Davis, Recreation Supervisor
Date: June 26, 2018
Subject: Early Learners
Recommendation
Authorize the City Manager to execute the Independent Contractor Agreement- Early Learners.
Background
The City of Lake Elsinore contracts with private instructors to perform recreational instruction at
City owned facilities such as the Lake Community Center and Lake Elsinore Senior Center. The
City of Lake Elsinore collects all of the registration fees for the classes through Recl, a software
program. Upon the City's receipt of invoice, the City then pays each of the contract instructors
75 percent of the participation Registration Fees collected. The City retains 25 percent of the
fees for facility maintenance and staffing costs.
Discussion
Early Learners is an existing business providing pre-school and ballet dance instruction at the
Lake Community Center. Due to Early Learner's popularity the last two years, they have
exceeded the City Manager's signing authority threshold of$30,000. We anticipate that they will
continue to maintain and potentially grow in popularity. Thus we anticipate Early Learners to
exceed the City Manager's signing authority threshold this year as well. As you shall find
attached in Exhibit A, Independent Contractor Agreement for Instruction — Early Learners is not
to exceed $70,000.
Fiscal Impact
Since the City collects the Registration Fees and then pays the Instructor their 75 percent dues,
the expenses are countered with the appropriate revenue stream and therefore, no fiscal impact
is anticipated.
Exhibits
A—Agreement
Page 1 of 1
a
INSTRUCTOR AGREEMENT CHECKLIST
In ructA—moLO Name- 1&6C Legal inessyl a E70 r)
Titll /Pasi ' :U ru & ors rr Q C Types f C s�.f qo 01 I(cf
Phone #: 1 y o q Fs-- p Email: q zm 10 � QVN0- ( I
Completed Agreement(2 original copies with wet signatures)
Business License (Copy)
Liability Insurance (Accord 25 Form)
$1 Million Per Occurrence
$2 Million General Aggregate
List "City of Lake Elsinore" as additionally insured
Automobile Insurance
• $100,000 Per Occurrence
• $300,000 General Aggregate
Worker's Compensation Insurance (Accord 25 Form, or if eligible, provide waiver)
$1 Million Per Occurrence
• $2 Million General Aggregate
Vendor Form (Only if new instructor with the City or change made to DBA)
W-9 Form (Only if new instructor with the City or change made to DBA)
Live Scan (Only if new instructor with City)
*Ail documentation must match legal "Doing Business As" name.
*All documentation must be valid. Instructor responsible updating documentation upon expiration.
*All documentation must be submitted together as one Agreement Package.
*Instructors must submit invoices based on rosters. Invoices will be processed within 45 days.
Instructor Signature Date
Official Use
City Official Name City Official Signature Date
CITY OF LAKE ELSINORE
INDEPENDENT CONTRACTOR AGREEMENT
FOR INSTRUCTION
THIS INDEPENDENT CONTRACTOR AGREEMENT FOR INSTRUCTORS ("Agreement") is made and
entered into on June 26,2018 by and between the CITY OF LAKE ELSINORE, hereinafter the"CITY,"and
Early Learners ,hereinafter the"CONTRACTOR."
1. Purpose.The CITY hereby engages CONTRACTOR for purposes of providing instruction in skillful and
competent manner,and shall abide by all laws in doing so.CONTRACTOR shall perform such other duties
as are customarily performed by one holding such position in other same or similar businesses or
enterprises as that engaged in by CITY and shall maintain instruction area in a clean, safe and orderly
manner.
2. Contractor's Status.CONTRACTOR is an independent contractor and is solely responsible for his or her
own actions or omissions.CONTRACTOR is not City's employee for any purpose.Any additional personnel
performing the services under this Agreement on behalf of CONTRACTOR shall also not be employees of
the CITY and shall at all times be under Contractor's direction and control. CONTRACTOR shall pay all
wages, salaries and other amounts due such personnel in connection with their performance of this
Agreement and as required by law.
3. Term.The term of this Agreement shall begin July 1,2018 and end June 30,2019.
4. Collection of Fees.Registration fees shall be collected by the CITY through set registration procedures
implemented by designated CITY staff.The CONTRACTOR is not authorized to collect registration fees.
Following the collection of registration fees,the CITY shall confirm the number of participants enrolled.The
CONTRACTOR will be compensated only for participants who have paid.
5. Compensation.In consideration of the performance of the instruction and/or services provided herein,the
CONTRACTOR shall receive seventy-five percent(75%)of the participation registration fees collected for
instruction and/or services identified in Section 1 above, exclusive of any facility entrance, pool use,
field/court night lights,insurance fees and/or publicity fees where charged.Compensation to be paid to the
Contractor shall not exceed$70,000 without prior additional written authorization from the City. It is also
understood that all taxes and/or other withholdings are the CONTRACTOR'S responsibility.
6. Payment.The compensation provided in Section 5 shall be paid upon satisfactory completion of instruction
and/or services and receipt of an invoice within 45 days by CONTRACTOR submitted to the Community
Services Department in the format specified by the Department,net 45 days.
7. Business License.Insurance.and LiveScan.CONTRACTOR and any subcontractor agrees to obtain
and follow all business license requirements as required by the Lake Elsinore Municipal Code, Chapter
5.08.All business license requirements must be met prior to contract approval.CONTRACTOR and any
subcontractor agrees to obtain all insurance required and present valid insurance certificates in accordance
with the attached Terms and Conditions.CONTRACTOR,its employees,agents,consultants,contractors
and volunteers agrees to perform and provide proof of LiveScan.
8. Terms and Conditions.This Agreement includes the terms and conditions as printed and set forth on the
following page,which terms and conditions are incorporated herein by reference;and the CONTRACTOR,
by executing this Agreement,agrees to comply with such terms and conditions.
CITY OF LAKE ELSINORE CONTRACTOR
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By: By: ` u1 :ir/ V, l�
Grant Yates,City Manager
Print Name:
Dated: 20_ Title: oil
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Business Name: l COYN a V V1
ATTEST:
Business Lzn=�y
Susan M. Domen,MMC,City Clerk Class(es):
Dated:
Address: �' t r
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20_ 'C V 0
City/State/Zip: �� n
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Email Address:
Phone Number:
TERMS AND CONDITIONS
1. EQUIPMENT AND LABOR: The Contractor shall goals. Contractor further acknowledges that failure
furnish all tools, equipment, apparatus, supplies and to do so will result in immediate termination of this
materials unless otherwise mutually agreed by City. Agreement.
Contractor assumes all risk of loss, damage or harm
to such equipment or materials arising in connection 8• COORDINATION OF WORK: The Contractor
with this Agreement.The Contractor shall perform the agrees to coordinate with the City specified time(s)
services under this Agreement in a skillful and and date(s) in order to avoid conflict of use. It is
competent manner and shall abide by all laws in doing agreed that the resolution of any conflict is at the
SO. sole discretion of the City Manager or his/her
designee. Contractor agrees to work with assigned
2. COMMUNITY HEALTH PROGRAM City staff to maintain accurate enrollment records.
PARTICIPATION: The Contractor shall participate in
the City's community health program by providing at 9• RULES: Contractor agrees to obey all rules and
least one hour of scheduled class services at least regulations of the City of Lake Elsinore and any
twelve times per year(i.e.once per month or during a directives and memoranda issued by the
seasonal series) free of charge to the program Department's Director.
participants.The location of the classes shall be at the
discretion of the City. 10. LIVESCAN: Contractor, its employees, agents,
consultants, contractors and volunteers must
3. SUBCONTRACTORS: In the event a contractor will comply with fingerprinting requirements, Public
not be able to teach class due to illness, etc. the Resources Code,Section 5164,by presenting proof
Contractor will implement the following procedure: of LiveScan to the City, prior to commencing work
with minors.
a. Contractor will procure a substitute contractor
equally or better qualified and acceptable to 11. HOLD HARMLESS AND INDEMNIFICATION. The
the City to instruct class at the prescribed time Contractor shall defend, indemnify, and hold
and place. Subcontractors must meet the harmless the City, its officials, officers, agents,
criminal background screening and employees and volunteers free and harmless from
fingerprinting requirements according to Cal any and all claims, demands, causes of action,
Public Resources Code Section 5164. costs, expenses, liability, loss,damage or injury, in
law or equity to property or persons, including
b. Contractor will notify assigned designated wrongful death, in any manner arising our of our
staff regarding the substitute's name, incident to any alleged acts, omissions or willful
qualifications, address and phone. Payment misconduct of Contractor, its employees, agents,
for subcontractors shall be responsibility of the consultants, contractors and volunteers arising out
Contractor. of or in connection with the performance of the
services in this Agreement, including without
c. If a substitute cannot be procured, the class limitation the payment of all consequential damages
will be canceled and a make up class added and attorneys' fees and other related costs and
to the end of the session. The contractor will expenses. Contractor shall pay and satisfy any
be responsible for notifying the students of the judgment, award or decree that maybe rendered
cancellation. against City or its officials, officers, employees,
agents, or volunteers, in any such suit, action or
d. Contractor is responsible for ensuring other legal proceeding. Contractor shall reimburse
subcontractors must meet all of the criteria City and its officials, officers, employees, agents,
stipulated in these Terms and Conditions, and/or volunteers for any and all legal expenses and
including but not limited to,maintaining a valid costs incurred by each of them in connection
City of Lake Elsinore Business License, therewith or in enforcing the indemnity herein
providing valid certificates of insurance in provided. Contractor's obligation to indemnify shall
accordance with City policies, and providing not be restricted to insurance proceeds, if any,
proof of LiveScan. received by the City, its officials, officers,
4. SUPERVISION: Contractor agrees to establish employees, agents or volunteers. Such
appropriate rules for conducting the class and to indemnification shall cover death or bodily injury to
assume responsibility for student discipline to ensure any person;injury to,loss,or theft of property,injury
adequate protection of students and facility. arising from the furnishing or use of any copyrighted
or uncopyrighted composition, secret process, or
5. FACILITY.The City shall be responsible for providing patented or unpatented invention,or any other type
a suitable facility for the conduct of the class, unless of injury,whether such injury or damage occurs on
otherwise noted under "Special Arrangements". or off City property.
Contractor shall pay City for any and all costs 12. INSURANCE: Contractor, its employees, agents,
associated with using the facility.Contractor agrees to consultants,contractors and volunteers understand
assume full responsibility for setting up any facility for that certain types of activities create additional
instruction and for cleaning and/or restoring the facility exposure of risk to City.Unless otherwise waived or
to its usual condition following each class session. modified by the City's Risk Manager,Contractor and
6. ACCESS TO FACILITY: City representatives shall at any agents, consultants, or subcontractors shall
all times have access to facility,whenever class is in similarly maintain the following insurance
progress to monitor programs for quality. requirements and present the applicable valid
certificates to the City of Lake Elsinore.Commercial
7. CONDUCT: Contractor understands that the City is a General Liability/Umbrella Insurance total limits
public entity under the laws of the State of California, shall be no less than $1,000,000 per accident and
and that the City's purpose in engaging Contractor is $2,000,000 general aggregate. Contractor shall
to provide its residents with recreational activities in a maintain automobile liability insurance covering
manner that will foster a sense of community,security, bodily injury and property damage for all activities of
fun and fair play. Contractor agrees to conduct the Contractor arising out of or in connection with
himself/herself in a manner that will further these the work to be performed under this Agreement,
TERMS AND CONDITIONS
including coverage for owned, hired and non-owned 19. GENERAL COMPLIANCE WITH LAWS.Contractor
vehicles, in an amount of not less than $300,000 shall comply with all federal, state, and local laws,
combined single limit for each occurrence.Contractor statutes, rules and regulations in any manner
shall maintain Workers'Compensation Insurance and affecting the performance of this Agreement.By law,
Employer's Liability Insurance for his/her employees Contractor,Contractor's employees and any agreed
in an amount not less than$1,000,000 in accordance upon substitute personnel or subcontractor must
with the laws of the State of California.Any notice of comply with the requirements of Cal Pub Resources
cancellation or non-renewal of all Workers' Code Section 5164 before engaging in the services
Compensation policies must be received by the City under this Agreement. Contractor, Contractor's
at least thirty (30) days prior to such change. The employees and any agreed upon substitute
insurer shall agree to waive all rights of subrogation personnel or subcontractor hereby agree to a
against City, its officers, agents, employees and criminal background check as required under Cal
volunteers for losses arising from work performed by Pub Resources Code Section 5164 by the City's
Contractor for City.City and its employees and agents Police Department if Contractor or any of Contractor
shall be added as additional insureds using ISO 's employees or agreed upon substitute personnel
additional insured endorsement form CG 20 10 or CG or subcontractor shall work with persons of eighteen
20 26 (in no event will City accept an endorsement (18)years of age or under.Contractor,Contractor's
form with an edition date later than 1990). Coverage employees or any agreed upon substitute personnel
shall apply on a primary non-contributing basis in or subcontractor must be cleared by City prior to
relation to any other insurance or self-insurance, working with persons of eighteen years of age of
primary or excess, available to City or any employee under. If the background check for Contractor,
or agent of City. Coverage shall not be limited to the Contractor's employees or agreed upon substitute
vicarious liability or supervisory role of any additional personnel or subcontractor reveals illegal or
insured. Contractors and subcontractors must objectionable information or activities,the person to
maintain this insurance requirement and have the City whom the background check applies shall be
listed as additionally insured in accordance with the prohibited from providing the services hereunder
above statements. and, in City's sole and absolute discretion, this
Agreement may be terminated, in which case
13. CONTRACTOR NOT OFFICER, EMPLOYEE OR Contractor will be entitled to no further
AGENT OF CITY.While engaged in carrying out the compensation under this Agreement. Contractor,
terms and conditions of the Agreement,the Contractor Contractor's employees, and any agreed upon
is an independent contractor and not an officer, substitute personnel or subcontractor shall not be
employee or agent of the City.The Contractor has no permitted to provide services hereunder for classes
authority, express or implied, to act on behalf of the with attendees who are eighteen years of age or
City as an agent or representative of the City under under unless a criminal background check has been
this Agreement to bind the City to any obligation.The performed and clearance has been received from
Contractor is not eligible for benefits from Social the Department of Justice.
Security, State Unemployment Insurance, Disability
Insurance or Workman's Compensation Insurance. In 20. MODIFICATION. No waiver, modification or
the event of injury, the Contractor is responsible for termination of this Agreement is valid unless made
his/her own medical expenses. in writing.
14. PUBLICITY: Contractor shall not advertise, print or 21. NONASSIGNMENT. Contractor shall not have any
publish any promotional materials in connection with right to assign and/or transfer his/her rights and/or
the instruction or service to be conducted under this obligations under this Agreement without the prior
Agreement without the prior written approval of the written consent of the City.
Director of Community Services or his/her authorized
representative. 22. DEFAULT BY CONTRACTOR: Failure to comply
with any of the terms and/or conditions of this
15. ASSUMPTION OF RISK. Contractor works at his/her agreement shall constitute default by the Contractor.
own risk. Contractor shall ensure each participant
signs the City's"Waiver& Release Agreement" prior 23.TERMINATION: The agreement may be terminated
to participation. by the City upon 30 days' notice given in writing.
Both parties will perform in accordance with the
16. COLLECTION OF FEES: The Contractor agrees not agreement prior to the effective termination date.
to accept any registration fees from students. All Nothing contained herein shall diminish the right of
registration fees shall be paid directly to the City and the City to cancel, immediately and without prior
the Contractor shall be paid at the conclusion of the notice, the agreement for cause without penalty or
course by the City. The Contractor may collect liability on the part of the City.
additional fees for materials and supply costs. The
Contractor shall appropriately inform the participants 24. ENTIRE AGREEMENT: This contract constitutes
of the additional material fees prior to registration. the entire Agreement between the parties
Participants may be required to bring certain supplies concerning the subject manner hereof and
and materials to class. supercedes all agreements, representations,
statements,promises and understandings,whether
17. PAYMENT OF FEES: City agrees to pay Contractor oral or written, with respect to the subject manner
according to compensation provision provided on first hereof.
page of this Agreement. Contractor is responsible for
payment to any subcontractors. 25. SPECIAL ARRANGEMENTS:
18.AMERICANS WITH DISABILITIES ACT. Contractor
agrees that he/she shall make every attempt to
accommodate people with physical and/or mental
disabilities.
1011
nu111111130 South Main Street J rr1 � 1•II_I• r
CITY c�F ���, Lake Elsinore, California 92530 DUE DATE
LADE � " LSI NORE PH (951)6743124 x302 FAX(95 471 0052
DREAM EXTREME
www lake-elsinore.orq 6/30/201'�
»�
BUSINESS LICENSE RENEWAL NOTICE
EXPIRATION DATE 6/30/2018 If business is no longer active in Lake
BUSINESS LICENSE NO. 017288 Elsinore,please eater closing date here,
Business EARLY LEARNERS
Phone No. (951)809-8569 sign and return to the address above.
Name and 31905 BIRCHWOOD DR Fax No. / I
Location -------_.__— - ------- - --
LAKE ELSINORE,CA 92530-2623 Start Date 7/13/2010 Closing Date
Rate Type General Business
Mailing EARLY LEARNERS
SIC Code 8351007 signature
Address 31905 BIRCHWOOD DR NAIC Code 611699
LAKE ELSINORE, CA 92530-2623 Ownership Sole Proprietor
Email Address
State License No.
License Type
Description of Business CLASS INSTRUCTOR Expiration Date
APN Federal ID No. State ID No. Resale No.
Owners,Partners,or Corporate Officers-Please make any necessary corrections.
Owner Name MARIA JAZMINE DELONE Title TEACHER Phone
Cell Phone
Home Address
Social Security No. Driver's Lic# E-Mail
Owner Name STEPHANIE SANGES Title TEACHER Phone
Horne Address Cell Phone
Social Security No. Driver's Lic# E-Mail
Emergency Contact-Please make any necessary corrections.
Name Title Phone
Address Cell Phone
RENEWAL INSTRUCTIONS Base Fee $ 72.00
You may be able to renew your business license online. Please visit
www.lake-elsinore.org for details. Employee Fee $
SUB-TOTAL:Add the Base Fee, Employee Fee,and Unit Fee to get the Sub-Total of Unit Fee $ 0.00
the License Fees. Enter this amount in the Sub Total box.
SUB TOTAL $
LICENSE FEES
EMPLOYEE FEE: ENTER TOTAL#OF EMPLOYEES -J- I r_f'I -i i `a� ,�. rt'I "' ray .T..> I( "1 -i" FN r
r , _Penalf'fj,4f any .:.$=; „ �,_, 1•i - -a
If# of employees Is 5 or less,enter zero(0)in the Employee Fee box. _ , *.§ r c,_ ,- r_ 1 .:_
If#of employees is more than 5,subtract 5 from#of employees= _ AdmEnlsrtiue R iwal
I `•=' I r_ ;°Fee `_:$a� •,_, i rrl 2�.00Multiply b $6.50. Enter this amount in Employee Fee box. - -, o? r- II M
r•.� r ram? a: n i a -. _, .
State CASp,�Fee + •$ _ .00 n t;
PENALTY: Penalties accrue at the rate of 25%per month,starting 15 days after the 1 _ lr r n
Due Date above. Penalties increase by 25%on the 15th day of each subsequent month ( r;,, !;, a --1 r
to a maximum penalty of 100%. If submitting this renewal after the Payment Due Previnu5 ahnce y$I_.._ _1 P-00
Date, please calculate the penalty based upon the Sub Total License Fees amount and
enter the correct penalty amount in the Penalty box.
TOTAL AMOU�TrbUE Q
-
TOTAL AMOUNT DUE:Add the Sub-Total amount, Penalty(if any), Renewal Fee, and
NOTICE: Underifedetar-19nd state raw,compirande withitlisability _ -'•
Previous Balance to get the Total Amount Due. accrl5s laws is a,5eiadus and signifid6t responlibility th��applies ;i,' ^'
to ali California huildtng owners and,tenants gyith._fioilding�open to i;;
the public. You may obtain inforn-ladio about your legal obligations ='
and�how to cort,ply with disability access;3A.ws at theifollowing
agencies: hhe Division of the
Architect at ;r' y'•
I declare under penalty of perjury of the laws of the State of California that the information wwk da_ s ca gov/dsa Home.aspx-The Department of Rehabilitation L
provided herein is true and correc. at v ww r hab ahwnet aov - The California Commission on
Disability AdLess atwww ccda.caaov.
Date
n
Signat r of ner r epresen a five Print Name
URN COMPLETED RENEWAL NOTICE TO ABOVE AD ESS WITH A CHECK PAYABLE TO CITY OF LAKE ELSINORE
Printed 6/8/2018.11:14 am online renewal pin #: 026110
EVANSTON INSURANCE COMPANY
CERTIFICATE NO.: 6365,11830655844164
CERTIFICATE OF INSURANCE
SPECIAL EVENT LIABILITY PROGRAM
PRODUCER PUBLIC ENTITY(ADDITIONAL INSURED)
Alliant Insurance Services,Inc.in conjunction with City of Lake Elsinore
Apex Insurance Services
P.O.Box 6450
Newport Beach,CA 92658
License No:OC 36861
NAMED INSURED(EVENT HOLDER): EVENT INFORMATION:
Early Learners TYPE: Ballet
31905 Birchwood St. DATE(S): 01/29/2018-12/21/2018
Lake Elsinore, CA 92532 LOCATION: Terra Cotta Gym and Lake Community Center
*Liquor Liability Yes No
"Liquor Liability after 12 am ends before 2 am ❑
This is to certify that the insurance policy listed below has been issued to the above insured named(event holder)for the policy
period indicated. The insurance described herein is subject to all the terms,exclusions and conditions of such policy(ies)unless
amended as described in Special Conditions.
INSURANCE CARRIER:Evanston Insurance Company
MASTER POLICY NUMBER: SEP41026
MASTER POLICY DATES: EFFECTIVE: January 01,2018 EXPIRATION: January 01, 2019
COMMERCIAL GENERAL LIABILITY General OCCURRENCE FORM DEDUCTIBLE: NONE
Aggregate Limit $2,000,000
Products&Completed Operations 1,000,000 SPECIAL CONDITIONS:
Personal&Advertising Injury 1,000,000 The following endorsements attached to
Each Occurrence Limit 1,000,000 the Master Policy do not apply to this
Damage To Premises Rented To You(Any One Premises) 100,000 Certificate Of Insurance:
Medical Payments(Any One Person) 5,000 MEGL1643
Liquor Liability (If purchased) 1,000,000
Optional Limits Purchased
❑ $1,000,0001$3,000,000
❑ $2,000,00052,000,000
Property Damage(If purchased)
No Property Damage Coverage
The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event.
OTHER ADDITIONAL INSUREDS
City of Lake Elsinore
CANCELLATION: Should the above described policy be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy
provisions.
AUTHORIZED REPRESENTATIVE: [�
DATE ISSUED: 01/10/2018
EVANSTON INSURANCE COMPANY
CERTIFICATE NO.: 6365-11827877515501
CERTIFICATE OF INSURANCE
SPECIAL EVENT LIABILITY PROGRAM
PRODUCER PUBLIC ENTITY(ADDITIONAL INSURED)
Alliant Insurance Services,Inc. in conjunction with City of Lake Elsinore
Apex Insurance Services
P.O.Box 6450
Newport Beach,CA 92658
License No:OC 36861
NAMED INSURED(EVENT HOLDER): EVENT INFORMATION:
Early Learners TYPE: Preschool/Daycare
31905 Birchwood Dr DATE(S): 01/10/2018-12/20/2018
Lake Elsinore, CA 92532 LOCATION: Lake Community Center
*Liquor Liability Yes No
"Liquor Liability after 12 am ends before 2 am ❑
This is to certify that the insurance policy listed below has been issued to the above insured named(event holder)for the policy
period indicated. The insurance described herein is subject to all the terms,exclusions and conditions of such policy(ies)unless
amended as described in Special Conditions.
INSURANCE CARRIER:Evanston Insurance Company
MASTER POLICY NUMBER: SEP41026
MASTER POLICY DATES: EFFECTIVE: January 01,2018 EXPIRATION: January 01, 2019
COMMERCIAL GENERAL LIABILITY General OCCURRENCE FORM DEDUCTIBLE: NONE
Aggregate Limit $2,000,000
Products&Completed Operations 1,000,000 SPECIAL CONDITIONS:
Personal&Advertising Injury 1,000,000 The following endorsements attached to
Each Occurrence Limit 1,000,000 the Master Policy do not apply to this
Damage To Premises Rented To You(Any One Premises) 100,000 Certificate Of Insurance:
Medical Payments(Any One Person) 5,000 MEGL1643
Liquor Liability (If purchased) 1,000,000
Optional Limits Purchased
❑ $1,000,000/$3,000,000
❑ $2,000,00052,000,000
Property Damage(If purchased)
No Property Damage Coverage
The limits of insurance apply separately to each event insured by this policy as if a separate policy of insurance has been issued for that event.
OTHER ADDITIONAL INSUREDS
City of Lake Elsinore
CANCELLATION: Should the above described policy be cancelled before the expiration date thereof,notice will be delivered in accordance with the policy
provisions.
AUTHORIZED REPRESENTATIVE:
DATE ISSUED: 01/10/2018
w
FARMERS
Auto Insurance Declaration Page INSURANCE
PolicyNumber: 18638-28-91 Premiums/Fees
. . . . ... . . .... . . . . . .. . . . . . .. . .. .. .. . . . . . .. . . . . . . . .. . . .
Effective: 5/3/2018 12:01 AM Policy Premium $895.40
Expiration: 1 1/3/201 8 1 2:01 AM
Named Insured(s):Jazmine Delone Fees(*also see Information on Additional $1.76
31905 Birchwood Dr Fees below)
Lake Elsinore,CA 92532-2623 !► Policy Premium and Fees $897,16
Underwritten By: Farmers Insurance Exchange
6301 Owensmouth Ave. This is not a bill.
Woodland Hills,CA 91367 Your bill with the amount due will be mailed separately.
Household Drivers
All persons who drive or will occasionally be driving any of the cars on the policy should be listed below.If anyone is missing or needs to
be added,such as a newly licensed driver,you should contact your agent or the company to add that person before they begin to drive
any of the cars covered on the policy.
Name Driver Status
Jazmine Delone Covered
Vehicle Information
Veh.# Year/Make/ModeVVIN Coverage Deductible Limit
1 Comprehensive: $1,000
Collision: $1,000
Additional Equipment: $1,000
2 Comprehensive: Not Covered
Collision: Not Covered
Additional Equipment: Not Covered
Coverage Information
Limits Premiums by Vehicle
Coverage (applicable to all vehicles) Vehicle 1 Vehicle 2
Bodily Injury Liability $100,000 each person $294.10 $312.10
$300,000 each accident
Property Damage Liability $50,000 each accident Included Included
Permissive User Limit of Full(See Permissive User Included Included
Liability" Limit of Liability in your
policy)
Medical Coverage Not Covered Not Covered
Uninsured Motorist Bodily $100,000 each person $46.10 $46.60
Injury $300,000 each accident
Comprehensive $29.80 Not Covered
Collision $158.00 Not Covered
farmers.com Policy No. 18638-28-91 Questions? Manage your account:
Call your agent Julian Palacios at(714) Go to www.farmers.com to access
529-4147 or email you r account any time!
jpalacios@farmersagent.com
56-6176 1st Edition 5-17 3/7/2018
Page 1 of 3
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE
I hereby certify that in the performance of the work for which this Agreement is
entered into, I shall not employ any person in any manner so as to become subject to the Worker's
Compensation Laws of the State of California.
Executed on this day of u�� 204 at Lake Elsinore, California.
r j Contractor Name